11/20/2009 @ 5:20PM

Worse Than You Think

How much of the $2.5 trillion the U.S. spends on health care goes down the drain for tests and treatments that don’t help, run up the bill and may even cause harm?

When it comes to financial threats to the u.s., President Obama says nothing even comes close to spiraling health care costs, expected to hit $2.5 trillion in the U.S. this year. Legislators are struggling to come up with health reform plans that cover millions more people without boosting the deficit.

One obvious place that Congress could look for savings: the waste already embedded in the medical system. Doctors like to believe that the vast majority of what they do is grounded in solid science. If only it were true. Just this summer trials found that a popular $3,000 procedure for treating back pain from osteoporosis was no better than a fake surgery. Top hospitals had been doing it for years. Minimally invasive prostate cancer surgery–often done with an expensive robot–is all the rage, thanks to supposed advantages over old-fashioned surgery. But so far it has left more people reporting impotence and incontinence, despite reducing other complications and hospital stays, a Journal of the American Medical Association analysis concluded in October.

Those continuous fetal heart rate monitors that hospitals strap on to women in labor? They don’t lower neonatal death rates, but they do boost the number of costly caesarean sections, big studies have found. What about expensive screening tests for heart disease? A big government trial last April found that giving one such test (myocardial perfusion imaging) to diabetics failed to lower their heart attack rate five years later.

Health policy researchers furiously debate how much is wasted on treatments that sometimes don’t make people better. There are no sure numbers because much of modern medicine remains unstudied and unproven, but by every indication the figure is colossal. Health spending is projected to hit 17.6% of gross domestic product this year. In 2008 the consultant firm McKinsey found $650 billion in excess medical costs, even after adjusting for the fact that rich nations spend more of their incomes on health. Elliott Fisher and his colleagues at Dartmouth Medical School have shown that medical spending fluctuates wildly from town to town and hospital to hospital, with no measurable improvement in health in the pricey places. They calculate that 20% or more of all costs could be eliminated without harming anyone. It might even save some lives by preventing complications from unnecessary treatments and hospital stays. At least 40% of all specialist visits and 25% of hospitals stays are unnecessary, Fisher estimates.

“We don’t have any sort of system to measure the effectiveness of what we are doing,” laments Dartmouth-Hitchcock Medical Center orthopedic surgeon James Weinstein. He showed in 2006 that patients with herniated spinal discs often get better on their own, without the need for back surgery. “For all of the money we spend, we are flying blind.”

Another strand of evidence comes from health researcher Robert Brook at UCLA and the Rand Corp. In the 1980s and early 1990s he looked at rates of unnecessary surgery for numerous procedures, including hysterectomy (removal of the uterus), various heart procedures and carotid endarterectomy to prevent stroke. “Across the board a large percentage of surgery was inappropriate or of questionable value,” he says–sometimes it was 30% or more.

Brook says no federal agency has been interested in funding his proposals to develop a broad set of surgical appropriateness criteria. “You’d think the federal government would make this a priority. But it is politically too hot to handle,” he says. Doctors aren’t always keen on taking a scientific look at whether they are wasting patients’ money. “Some people don’t want to know,” says Manchester, N.H. cardiologist Michael Hearne, who says he got a skeptical reaction from some colleagues when he proposed evaluating whether all the stent procedures done at his hospital were necessary. “There is this attitude of ‘Why bother? I know what I am doing is right.’ But that’s not always the case.”

Wasteful medicine can be profitable. “Every time you isolate a place where we are wasting money and there is something we can do about it, it takes money out of someone’s pocket,” says Wendy Everett, who heads New England Healthcare Institute, a nonprofit research outfit.

American consumers share the blame. They often falsely equate fancy tests with high-quality care. “There is an assumption that more testing is better care. People don’t trust their physicians and assume they aren’t doing a good job if they don’t order more tests,” says Richard Deyo, a back pain expert at Oregon Health & Science University in Portland. “Even my wife tells me, ‘This wasn’t a good doctor; he didn’t do any tests.’” But tests that aren’t done for solid reasons can generate misleading results, he says.

Here are some tests and treatments Congress could target if it decides to get serious about controlling health care costs:

High-Tech Imaging

A miracle of modern medicine, the computed tomography machine (CT) takes crystal-clear cross- sectional pictures of the body in a few seconds, using high-tech X-rays. Seventy million scans are done annually, at a cost of $200 or more, compared with only 3 million in 1980. Tens of millions more get magnetic resonance imaging (MRI) scans.

It’s a seductive, reassuring and quick technology, for both patients and doctors, but do you always need these scans? “From what I see in emergency rooms, 30% to 40% of computed tomography scans are not indicated,” says radiologist Stephen Baker of the University of Medicine & Dentistry of New Jersey. He says that all too often scans are ordered for relatively benign conditions such as kidney stones or stomachaches with no alarming symptoms. Even in kids with head injuries, a 42,000-patient study published in the Lancet in September found, scans can be skipped in 20% who don’t have other indicators of serious brain injury. Primary care docs don’t always know when scans are really needed; one Australian study found that 34 of 50 CT scans ordered by general practitioners were unnecessary.

Scans aren’t totally benign. CT scans use approximately 100 times as much radiation as plain chest X-rays. Four million Americans each year get a relatively high radiation dose from multiple types of imaging, raising their future cancer risk slightly, a New England Journal of Medicine study estimated in August. After his daughter got nine scans after being hit by a car, New Hampshire radiologist Steven Birnbaum got records from his own hospitals and found 150 young adults had gotten multiple scans for benign problems. “I was horrified,” he says.

A more insidious side effect of excess scans is false positives, which can lead to unnecessary treatment. “Mother Nature makes little lumps and bumps in the body; we cannot explain them all,” says Massachusetts General Hospital radiologist James Thrall.

So why are they overused? One reason is that they are a fast and easy way for busier docs to rule out serious problems. Patients may expect a scan.

Then there is the profit motive. Doctors used to refer patients to radiologists for scans. But now many nonradiologists are buying their own machines and getting a cut of the revenue. This may be convenient for patients, but various studies have found that doctors who have their own machines order scans more frequently than doctors who don’t.

Mental Health Treatments

Last year new schizophrenia drugs such as Seroquel from
AstraZeneca
and Zyprexa from
Eli Lilly
edged out cholesterol drugs at the top of the sales charts, with well over $14 billion in sales, according to ims Health. These and other so-called atypical antipsychotics rose to prominence on the belief they were clearly better and safer than older drugs. At least that’s what studies commissioned by the drug vendors supposedly showed. But in 2005 a 1,493-patient government trial challenged this, showing that the new drugs were generally not much better and came with side effects, such as rapid weight gain. (Zyprexa had the lowest discontinuation rate, an efficacy measure.) Last year another government trial found that atypical drugs were no better in kids, either. “Marketing, marketing and marketing” drove the uptake, says Yale University psychiatrist Robert Rosenheck. “They created the notion that this was a new class of medications and a breakthrough.”

The pricey antipsychotics are prescribed for all sorts of unapproved uses, including in kids with attention-deficit disorder or behavior problems. “They are used a little wantonly,” says Columbia University psychiatrist Jeffrey Lieberman. Seroquel is often given as a sleep aid, says Yale’s Rosenheck, despite costing far more than generic Ambien. “It is a waste of money and one of the reasons we haven’t been able to control health care costs,” he says. The wide use is “without scientific justification.”

Nursing homes frequently use schizophrenia drugs to treat agitated Alzheimer’s patients, even though the drugs boost the death rate in these people and a 421-patient trial showed that they have very limited effectiveness. “Nursing homes don’t care about the cost of the medications” because the government is paying, says University of Southern California Alzheimer’s researcher Lon Schneider.

Eli Lilly psychiatrist Robert Conley says new drugs are needed because individual patients respond differently. “Patients very much need choices,” he says. Both Eli Lilly and AstraZeneca point to some studies showing that the newer generation drugs have lower rates of certain important neurologic side effects.

In January Eli Lilly agreed to pay $1.42 billion and plead guilty to a charge it marketed Zyprexa for unapproved use.
Pfizer
, denying wrongdoing, has agreed to pay the feds $301 million to settle allegations it promoted its antipsychotic Geodon off-label.

By the Numbers

$1,657 Monthly cost1 of treating schizophrenia with Seroquel.

$1,433 Monthly cost1 of treating schizophrenia with Zyprexa.

$1,131 Monthly cost1 of treating schizophrenia with old drug (perphenazine).

Investigations of Fainting Spells

Half a million Americans are hospitalized each year after they report to the emergency room with fainting spells. The condition is usually benign, unless there are signs of heart problems. Yet Americans spend billions on hospital care and fancy tests in an often futile quest for a cause.

One study of 2,106 elderly patients admitted to Yale-New Haven Hospital found that 63% got head CT scans, 95% got cardiac enzyme tests, while others got electroencephalograms and other exotic tests. The expensive tests were rarely helpful, the study found. A $5 postural blood pressure test was much more useful but performed on only 38% of patients. “It is rarely done because it takes time,” explains Yale University professor of medicine Mary Tinetti, who led the study.

Doctors in other countries like Canada hospitalize far fewer people after fainting spells, yet “they don’t have people dying all over the place,” says Stanford University emergency medicine specialist James Quinn, who has developed a set of rules to pluck out patients at high risk.

By the Numbers

$6 billion Estimated total spending on tests to determine causes of fainting spells.

63% of patients with fainting spells got $525 head CT scans at one hospital.

2% of the time it made a difference in the diagnosis.

38% of fainting patients got $5 postural blood pressure test.

26% of the time it made a difference in diagnosis.

Source: Archives of Internal Medicine, July 27, 2009.

Back Pain Treatments

Former computer programmer Laura Held, 52, spent years suffering from herniated discs in her upper spine that sent waves of pain shooting down her arms. So in 2006 she underwent a newly invented operation that replaced three of her worn-down discs with artificial ones, even though her insurance wouldn’t pay the $10,000 cost.

But the relief was temporary and the complications long-lasting, she says. The operation paralyzed her left vocal cord, making speaking and swallowing difficult for months. Her voice is still noticeably raspy. The neck pain returned after a year. Held has already generated $100,000 in bills and now faces the prospect of another operation to fix the problems caused by the first one. “She bought a bill of goods,” says University of California, Irvine spine surgeon Charles Rosen.

Spending on back and neck pain treatments, including prescription narcotics, increased 65% (after inflation) between 1997 and 2005 to $86 billion, a 2008 Journal of the American Medical Association study found. Yet the study found no evidence all the spending was making people feel better.

Back surgery is getting ever more complicated and expensive. One controversial operation that has surged in popularity is spinal fusion, in which two or more vertebrae are fused together to alleviate pain blamed on degenerated discs. It costs around $50,000. Two controlled trials, one in England and one in Norway, found it was hardly better for plain lower back pain than a good rehab program combining exercise and cognitive therapy. The surgery comes with more complications than the exercise.

By the Numbers

33.3 million Americans report back and neck pain.

$86 billion Total spending on back and neck pain treatments.

65% Rise in spending since 1997 (inflation adjusted).

20.7% Percent of back patients with limitations in physical function in 1997.

24.7% Percent of back patients with limitations in physical function in 2005.

Angioplasty and Stents

One million Americans a year get artery-widening stents in a surgical procedure that costs $20,000. Stents save lives if inserted immediately after heart attacks. But stents don’t save lives or prevent heart attacks in most patients with stable heart disease symptoms, two giant trials have now shown. Intensive drug therapy can do just as well without the risks of an invasive procedure.

Few careful studies have looked at how many angioplasties are really necessary. (Stents are installed during angioplasty, in which a balloon is used to unclog an artery; it is an alternative to bypass surgery.) But one Rand study in 1993 found that 4% of angioplasties done in New York were clearly inappropriate and another 38% were of questionable benefit. Since then stents were introduced, and angioplasties have exploded in popularity. A 2005 study examining a database of 412,000 stent procedures found that 8% of patients got stents they definitely shouldn’t have; those who got unnecessary stents were more likely to have complications.

Some cardiologists have an almost religious belief in the high-tech approach. A 2007 focus group of 20 cardiologists found that they would recommend stents for any significant narrowing seen on an angiogram, even if patients had no symptoms. “People don’t realize that useless procedures can be dangerous,” says McMaster University cardiologist Salim Yusuf, since any procedure can lead to repeat procedures and complications.

19% Chances this person will die or suffer a heart attack within 4.6 years.

$752 Initial cost of treating stable heart patient with drugs only.

18.5% Chances this person will die or suffer a heart attack within 4.6 years.

32.6 Percentage of drug therapy patients who later needed stents or surgery.

Sources: New England Journal of Medicine; Circulation.

Knee Arthroscopy in Arthritis

One common way to treat arthritis of the knee has been to shave off loose pieces of cartilage through arthroscopic surgery. Two rigorous trials show that this $5,000 procedure doesn’t help. In 2002 researchers at the va Medical Center in Houston showed that the real operation was no better than a fake (placebo) operation for arthritic knees. But some surgeons refused to accept the verdict, even as Medicare stopped covering the procedure for arthritis alone. (It is widely used for sports injuries.) They argued that the veterans study reflected a narrow demographic and that patients with locking or other “mechanical” symptoms could still benefit. Doctors performed 956,000 knee arthroscopies in 2006, up from 629,000 in 1996. How many are done in arthritis sufferers is unknown.

Orthopedic surgeon Robert Litchfield of the University of Western Ontario in Canada thought his trial, comparing arthroscopy to treatment with painkillers and physical therapy in 176 arthritis patients, would disprove the earlier one. But after two years those who got operations were no better, including those with mechanical symptoms, according to the results reported last year in the New England Journal of Medicine.

A murky situation is patients with some arthritis and with tears in the meniscus, the knee’s shock absorber. Most arthritis patients have the tears, whether they are in pain or not. “This is one of the most frequently performed procedures in medicine, and we don’t know whether it works,” says Brigham & Women’s Hospital rheumatologist Jeffrey Katz, who is leading another trial to resolve the matter.